Child Private / Semi Private Registration

Child's Name *

First

Last

Childs D.O.B *

Child's Age *

Gender

Male
Female

If you have a second child, you MUST complete a separation registration form for that child.

Parent/Guardian's Name

Are you an employee?

Yes
No

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work Number

Cell Phone

Email *

Instructor Preferance for private or semi-private lessons

Time Preference

AM
PM

An instructor will reach out to schedule a time.

Member *

Private | $205
Semi-private | $290 ($145 per child)
I'm not a member

Non-Member *

Private | $245
Semi-private | $330 ($165 per child)
I'm a member

All non-members must make an appointment to sign a guest waiver and pay in person. Email: charlotte.boswell@genesishealthclubs.com

Payment Info *

Payment must be made to ensure your spot

Signature *

Clear Signature

I accept full responsibility for my use of any and all apparatus, appliances facility privilege or service whatsoever, owned and operated by this Club at my own risk and shall hold this Club, its shareholders, directors, officers, employees, representatives, and agents harmless from any and all loss, claim, injury, damage or liability sustained or incurred by me resulting therefrom. By completing this form you agree that we may communicate with you by phone, or by using electronic communications such as email and text messaging. Your information will not be sold by Genesis Health Clubs.

Date / Time

Date

Time

Promotional Code (Optional)

Full Name *

First

Last

Phone

Email *